Advancing patient-centered research practices in a pragmatic patient-level randomized clinical trial: A thematic analysis of stakeholder engagement in Emergency Medicine Palliative Care Access (EMPallA).

BACKGROUND: Involving patient and community stakeholders in clinical trials adds value by ensuring research prioritizes patient goals both in conduct of the study and application of the research. The use of stakeholder committees and their impact on the conduct of a multicenter clinical trial have been underreported clinically and academically. The aim of this study is to describe how Study Advisory Committee (SAC) recommendations were implemented throughout the Emergency Medicine Palliative Care Access (EMPallA) trial. EMPallA is a multi-center, pragmatic two-arm randomized controlled trial (RCT) comparing the effectiveness of nurse-led telephonic case management and specialty, outpatient palliative care of older adults with advanced illness. METHODS: A SAC consisting of 18 individuals, including patients with palliative care experience, members of healthcare organizations, and payers was convened for the EMPallA trial. The SAC engaged in community-based participatory research and assisted in all aspects from study design to dissemination. The SAC met with the research team quarterly and annually from project inception to dissemination. Using meeting notes and recordings we completed a qualitative thematic analysis using an iterative process to develop themes and subthemes to summarize SAC recommendations throughout the project's duration. RESULTS: The SAC convened 16 times between 2017 and 2020. Over the course of the project, the SAC provided 41 unique recommendations. Twenty-six of the 41 (63%) recommendations were adapted into formal Institutional Review Board (IRB) study modifications. Recommendations were coded into four major themes: Scientific, Pragmatic, Resource and Dissemination. A majority of the recommendations were related to either the Scientific (46%) or Pragmatic (29%) themes. Recommendations were not mutually exclusive across three study phases: Preparatory, execution and translational. A vast majority (94%) of the recommendations made were related to the execution phase. Major IRB study modifications were made based on their recommendations including data collection of novel dependent variables and expanding recruitment to Spanish-speaking patients. CONCLUSIONS: Our study provides an example of successful integration of a SAC in the conduct of a pragmatic, multi-center RCT. Future trials should engage with SACs in all study phases to ensure trials are relevant, inclusive, patient-focused, and attentive to gaps between health care and patient and family needs. TRIAL REGISTRATION: Clinicaltrials.gov Identifier: NCT03325985, 10/30/2017.

Clinical research should involve patient and community stakeholder perspectives to make sure the study addresses questions important to the studied population. One way to do this is by creating a group of stakeholders who can advise on the conduct of a study. We assembled a Study Advisory Committee (SAC) for the Emergency Medicine Palliative Care Access (EMPallA) trial. The purpose of this clinical trial is to compare the effectiveness of nurse-led telephonic case management and specialty, outpatient palliative care of older adults with advanced illness. This paper describes how the SACs involvement translated into direct impacts on the EMPallA trial. The trial research team held regular meetings with the SAC throughout the trial process. Their involvement led to many significant changes in the trial, such as  expanding recruitment inclusion criteria (Spanish-speaking patients), and including survey instruments to measure lonelines and caregiver burden. The SAC also devised strategies to overcome patient and caregiver recruitment and retention challenges, including the creation of patient-friendly materials and training for research coordinators. This study provides a successful example of how actively engaging patient and community stakeholders, through committee engagement, can promote patient priorities in all phases of a trial while facilitating patient recruitment and retention.

Implementation of an Acute Care COPD Exacerbation Patient Mobilization Tool. A Mixed-Methods Study.

Background: Improving the mobility of hospitalized patients with an acute exacerbation of chronic obstructive pulmonary disease (AECOPD) is a priority of care. AECOPD-Mob is a clinical decision-making tool for physical therapists, especially those who are newly graduated or are new to caring for patients with AECOPDs in acute care settings. Although this tool has been available for several years, dissemination via publication is not sufficient to implement it in clinical practice.Objective: The primary objective of this study was to develop, implement, and evaluate different formats of AECOPD-Mob in an acute care setting.Methods: We used a mixed-methods, convergent parallel design. In addition to the paper format of AECOPD-Mob, we developed a smartphone app, a web-based learner module, and an in-service learning session. Newly graduated physical therapists (PTs) or PTs new to the practice area were recruited from urban acute care hospitals. Participants used the different formats for 3 weeks and then completed the Post-Study System Usability Questionnaire. User data were retrieved for the learning module. Participants participated in focus groups at 3 weeks and 3 months.Results: Eighteen (72% of eligible PTs, 100% female, 94% graduated within 3 yr) PTs participated. Post-Study System Usability Questionnaire scores for the learning module and smartphone indicated that participants were satisfied with these formats (median score 2.0 on 1-7 Likert Scale for both technology formats, lower scores indicating greater satisfaction). However, the participants reported in the focus group that the paper format was preferred over other formats. Concerns with the smartphone app included infection control and the perception of lack of professionalism when using a smartphone during clinical practice. The learning module and in-service were considered helpful as an introduction but not as an ongoing support. The paper format was seen as the most efficient way to access the necessary information and to facilitate communication between other members of the care team about the importance of mobility for hospitalized patients with AECOPDs.Conclusion: Newly graduated PTs strongly preferred the paper format of the AECOPD-Mob tool in the acute care setting. Future research will focus on knowledge translation strategies for other health disciplines.

Development and protocol for a nurse-led telephonic palliative care program.

BACKGROUND: The COVID-19 pandemic has resulted in a profound transformation of health care delivery toward telemedicine models. PURPOSE: We present the structure of a nurse-led telephonic palliative program and operational metrics to influence further development of tele-palliative programs. METHODS: The nurses engage with seriously ill patients for 6 months with the goal of discussing advance care planning (ACP) and addressing self-identified issues related to their illness. FINDINGS: Of the first 100 program graduates, 78% were actively engaged and 51% named a health care agent and/or engaged in ACP. Of the 18 patients who died during the study, 13 (72%) were enrolled in hospice services. DISCUSSION: Our preliminary results indicate that seriously ill patients are willing to engage with nurses and to participate with discussions on ACP. CONCLUSION: Given the gaps in health care exposed by the COVID-19 pandemic, this innovative program serves as an important model for bringing palliative care directly to patients.

Effectiveness and Reach of the Primary Palliative Care for Emergency Medicine (PRIM-ER) Pilot Study: a Qualitative Analysis.

BACKGROUND: Palliative care interventions in the ED capture high-risk patients at a time of crisis and can dramatically improve patient-centered outcomes. OBJECTIVE: To understand the facilitators that contributed to the success of the Primary Palliative Care for Emergency Medicine (PRIM-ER) quality improvement pilot intervention. DESIGN: Effectiveness was evaluated through semi-structured interviews. Reach outcomes were measured by percent of all full-time emergency providers (physicians, physician assistants, nurses) who completed the intervention education components and baseline survey assessing attitudes and knowledge on end-of-life care. PARTICIPANTS: Emergency medicine providers affiliated with two medical centers (N = 197). Interviews conducted with six key informants at both institutions. APPROACH: Interviews were recorded, transcribed, and analyzed using deductive and inductive approaches. Descriptive statistics include reach outcomes and baseline survey results. KEY RESULTS: Both sites successfully implemented all components of the intervention and achieved a high level (> 75%) of intervention reach. Two themes emerged as facilitators to successful effectiveness facilitators of PRIM-ER: (1) institutional leadership support and (2) leveraging established quality improvement (QI) processes. Institutional support included leveraging leadership with authority to (a) mandate trainings; (b) substitute PRIM-ER education for normally scheduled education; and (c) provide protected time to implement intervention components. Effectiveness was also enhanced by capitalizing on existing QI processes which included (a) leveraging interdisciplinary partnerships and communication plans and (b) monitoring performance improvement data. CONCLUSIONS: Capitalizing on strong institutional leadership support and established QI processes enhanced the reach and effectiveness of the PRIM-ER pilot. These findings will guide the PRIM-ER researchers in scaling up the intervention in the remaining 33 sites, as well as enhance the planning of other complex quality improvement interventions in clinical settings. REGISTRATION DETAILS: ClinicalTrials.gov Identifier: NCT03424109; Grant Number: AT009844-01.

Design and implementation of a clinical decision support tool for primary palliative Care for Emergency Medicine (PRIM-ER).

BACKGROUND: The emergency department is a critical juncture in the trajectory of care of patients with serious, life-limiting illness. Implementation of a clinical decision support (CDS) tool automates identification of older adults who may benefit from palliative care instead of relying upon providers to identify such patients, thus improving quality of care by assisting providers with adhering to guidelines. The Primary Palliative Care for Emergency Medicine (PRIM-ER) study aims to optimize the use of the electronic health record by creating a CDS tool to identify high risk patients most likely to benefit from primary palliative care and provide point-of-care clinical recommendations. METHODS: A clinical decision support tool entitled Emergency Department Supportive Care Clinical Decision Support (Support-ED) was developed as part of an institutionally-sponsored value based medicine initiative at the Ronald O. Perelman Department of Emergency Medicine at NYU Langone Health. A multidisciplinary approach was used to develop Support-ED including: a scoping review of ED palliative care screening tools; launch of a workgroup to identify patient screening criteria and appropriate referral services; initial design and usability testing via the standard System Usability Scale questionnaire, education of the ED workforce on the Support-ED background, purpose and use, and; creation of a dashboard for monitoring and feedback. RESULTS: The scoping review identified the Palliative Care and Rapid Emergency Screening (P-CaRES) survey as a validated instrument in which to adapt and apply for the creation of the CDS tool. The multidisciplinary workshops identified two primary objectives of the CDS: to identify patients with indicators of serious life limiting illness, and to assist with referrals to services such as palliative care or social work. Additionally, the iterative design process yielded three specific patient scenarios that trigger a clinical alert to fire, including: 1) when an advance care planning document was present, 2) when a patient had a previous disposition to hospice, and 3) when historical and/or current clinical data points identify a serious life-limiting illness without an advance care planning document present. Monitoring and feedback indicated a need for several modifications to improve CDS functionality. CONCLUSIONS: CDS can be an effective tool in the implementation of primary palliative care quality improvement best practices. Health systems should thoughtfully consider tailoring their CDSs in order to adapt to their unique workflows and environments. The findings of this research can assist health systems in effectively integrating a primary palliative care CDS system seamlessly into their processes of care. TRIAL REGISTRATION: ClinicalTrials.gov Identifier: NCT03424109. Registered 6 February 2018, Grant Number: AT009844-01.

Development of an Outpatient Palliative Care Protocol to Monitor Fidelity in the Emergency Medicine Palliative Care Access Trial.

Introduction: Palliative care is recommended for patients with life-limiting illnesses; however, there are few standardized protocols for outpatient palliative care visits. To address the paucity of data, this article aims to: (1) describe the elements of outpatient palliative care that are generalizable across clinical sites; (2) achieve consensus about standardized instruments used to assess domains within outpatient palliative care; and (3) develop a protocol and intervention checklist for palliative care clinicians to document outpatient visit elements that might not normally be recorded in the electronic heath record. Methods: As part of a randomized control trial of nurse-led telephonic case management versus specialty, outpatient palliative care in older adults with serious life-limiting illnesses in the Emergency Department, we assessed the structural characteristics of outpatient care clinics across nine participating health care systems. In addition, direct observation of outpatient palliative care visits, consultation from content experts, and survey data were used to develop an outpatient palliative care protocol and intervention checklist. Implementation: The protocol and checklist are being used to document the contents of each outpatient palliative care visit conducted as a part of the Emergency Medicine Palliative Care Access (EMPallA) trial. Variation across palliative care team staffing, clinic session capacity, and physical clinic model presents a challenge to standardizing the delivery of outpatient palliative care.

Primary Palliative Care for Emergency Medicine (PRIM-ER): Protocol for a Pragmatic, Cluster-Randomised, Stepped Wedge Design to Test the Effectiveness of Primary Palliative Care Education, Training and Technical Support for Emergency Medicine.

INTRODUCTION: Emergency departments (ED) care for society's most vulnerable older adults who present with exacerbations of chronic disease at the end of life, yet the clinical paradigm focuses on treatment of acute pathologies. Palliative care interventions in the ED capture high-risk patients at a time of crisis and can dramatically improve patient-centred outcomes. This study aims to implement and evaluate Primary Palliative Care for Emergency Medicine (PRIM-ER) on ED disposition, healthcare utilisation and survival in older adults with serious illness. METHODS AND ANALYSIS: This is the protocol for a pragmatic, cluster-randomised stepped wedge trial to test the effectiveness of PRIM-ER in 35 EDs across the USA. The intervention includes four core components: (1) evidence-based, multidisciplinary primary palliative care education; (2) simulation-based workshops; (3) clinical decision support; and (4) audit and feedback. The study is divided into two phases: a pilot phase, to ensure feasibility in two sites, and an implementation and evaluation phase, where we implement the intervention and test the effectiveness in 33 EDs over 2 years. Using Centers for Medicare and Medicaid Services (CMS) data, we will assess the primary outcomes in approximately 300 000 patients: ED disposition to an acute care setting, healthcare utilisation in the 6 months following the ED visit and survival following the index ED visit. Analysis will also determine the site, provider and patient-level characteristics that are associated with variation in impact of PRIM-ER. ETHICS AND DISSEMINATION: Institutional Review Board approval was obtained at New York University School of Medicine to evaluate the CMS data. Oversight will also be provided by the National Institutes of Health, an Independent Monitoring Committee and a Clinical Informatics Advisory Board. Trial results will be submitted for publication in a peer-reviewed journal. TRIAL REGISTRATION NUMBER: NCT03424109; Pre-results.

Drug Hypersensitivity due to Azathioprine with Elevated Procalcitonin.

We present a case of azathioprine hypersensitivity presenting as sepsis with elevated procalcitonin in a 68-year-old man with myasthenia gravis. The patient presented with fever, chills, nausea, vomiting, and headache. He developed numerous 1 cm erythematous papules over his upper torso. Infectious workup including bacteriological tests and microbial cultures was negative and a skin biopsy was performed which revealed suppurative folliculitis with eosinophils, consistent with drug hypersensitivity. Notably, acute phase reactants including C-reactive protein and procalcitonin were elevated upon presentation, likely secondary to drug hypersensitivity.

Unified Theory for Decoding the Signals from X-Ray Florescence and X-Ray Diffraction of Mixtures.

For research and development or for solving technical problems, we often need to know the chemical composition of an unknown mixture, which is coded and stored in the signals of its X-ray fluorescence (XRF) and X-ray diffraction (XRD). X-ray fluorescence gives chemical elements, whereas XRD gives chemical compounds. The major problem in XRF and XRD analyses is the complex matrix effect. The conventional technique to deal with the matrix effect is to construct empirical calibration lines with standards for each element or compound sought, which is tedious and time-consuming. A unified theory of quantitative XRF analysis is presented here. The idea is to cancel the matrix effect mathematically. It turns out that the decoding equation for quantitative XRF analysis is identical to that for quantitative XRD analysis although the physics of XRD and XRF are fundamentally different. The XRD work has been published and practiced worldwide. The unified theory derives a new intensity-concentration equation of XRF, which is free from the matrix effect and valid for a wide range of concentrations. The linear decoding equation establishes a constant slope for each element sought, hence eliminating the work on calibration lines. The simple linear decoding equation has been verified by 18 experiments.

Mesoscale elastic properties of marine sponge spicules.

Marine sponge spicules are silicate fibers with an unusual combination of fracture toughness and optical light propagation properties due to their micro- and nano-scale hierarchical structure. We present optical measurements of the elastic properties of Tethya aurantia and Euplectella aspergillum marine sponge spicules using non-invasive Brillouin and Raman laser light scattering, thus probing the hierarchical structure on two very different scales. On the scale of single bonds, as probed by Raman scattering, the spicules resemble a combination of pure silica and mixed organic content. On the mesoscopic scale probed by Brillouin scattering, we show that while some properties (Young's moduli, shear moduli, one of the anisotropic Poisson ratios and refractive index) are nearly the same as those of artificial optical fiber, other properties (uniaxial moduli, bulk modulus and a distinctive anisotropic Poisson ratio) are significantly smaller. Thus this natural composite of largely isotropic materials yields anisotropic elastic properties on the mesoscale. We show that the spicules' optical waveguide properties lead to pronounced spontaneous Brillouin backscattering, a process related to the stimulated Brillouin backscattering process well known in artificial glass fibers. These measurements provide a clearer picture of the interplay of flexibility, strength, and material microstructure for future functional biomimicry.

Dual Element Intercalation into 2D Layered Bi2Se3 Nanoribbons.

We demonstrate the intercalation of multiple zero-valent atomic species into two-dimensional (2D) layered Bi2Se3 nanoribbons. Intercalation is performed chemically through a stepwise combination of disproportionation redox reactions, hydrazine reduction, or carbonyl decomposition. Traditional intercalation is electrochemical thus limiting intercalant guests to a single atomic species. We show that multiple zero-valent atoms can be intercalated through this chemical route into the host lattice of a 2D crystal. Intermetallic species exhibit unique structural ordering demonstrated in a variety of superlattice diffraction patterns. We believe this method is general and can be used to achieve a wide variety of new 2D materials previously inaccessible.

Clinical Decision-Making Tool for Safe and Effective Prescription of Exercise in Acute Exacerbations of Chronic Obstructive Pulmonary Disease: Results From an Interdisciplinary Delphi Survey and Focus Groups.

BACKGROUND: Exercise is recommended for people with an acute exacerbation of chronic obstructive pulmonary disease (AECOPD), yet there is little information to guide safe and effective mobilization and exercise for these patients. OBJECTIVES: The purpose of this study was to develop a clinical decision-making tool to guide health care professionals in the assessment, prescription, monitoring, and progression of mobilization and therapeutic exercise for patients with AECOPD. DESIGN AND METHODS: A 3-round interdisciplinary Delphi panel identified and selected items based on a preselected consensus of 80%. These items were summarized in a paper-based tool titled Mobilization in Acute Exacerbations of Chronic Obstructive Pulmonary Disease (AECOPD-Mob). Focus groups and questionnaires were subsequently used to conduct a sensibility evaluation of the tool. RESULTS: Nine researchers, 13 clinicians, and 7 individuals with COPD identified and approved 110 parameters for safe and effective exercise in AECOPD. These parameters were grouped into 5 categories: (1) "What to Assess Prior to Mobilization," (2) "When to Consider Not Mobilizing or to Discontinue Mobilization," (3) "What to Monitor During Mobilization for Patient Safety," (4) "How to Progress Mobilization to Enhance Effectiveness," and (5) "What to Confirm Prior to Discharge." The tool was evaluated in 4 focus groups of 18 health care professionals, 90% of whom reported the tool was easy to use, was concise, and would guide a health care professional who is new to the acute care setting and working with patients with AECOPD. LIMITATIONS: The tool was developed based on published evidence and expert opinion, so the applicability of the items to patients in all settings cannot be guaranteed. The Delphi panel consisted of health care professionals from Canada, so items may not be generalizable to other jurisdictions. CONCLUSIONS: The AECOPD-Mob provides practical and concise information on safe and effective exercise for the AECOPD population for use by the new graduate or novice acute care practitioner.

Wireless gigabit data telemetry for large-scale neural recording.

Implantable wireless neural recording from a large ensemble of simultaneously acting neurons is a critical component to thoroughly investigate neural interactions and brain dynamics from freely moving animals. Recent researches have shown the feasibility of simultaneously recording from hundreds of neurons and suggested that the ability of recording a larger number of neurons results in better signal quality. This massive recording inevitably demands a large amount of data transfer. For example, recording 2000 neurons while keeping the signal fidelity ( > 12 bit, > 40 KS/s per neuron) needs approximately a 1-Gb/s data link. Designing a wireless data telemetry system to support such (or higher) data rate while aiming to lower the power consumption of an implantable device imposes a grand challenge on neuroscience community. In this paper, we present a wireless gigabit data telemetry for future large-scale neural recording interface. This telemetry comprises of a pair of low-power gigabit transmitter and receiver operating at 60 GHz, and establishes a short-distance wireless link to transfer the massive amount of neural signals outward from the implanted device. The transmission distance of the received neural signal can be further extended by an externally rendezvous wireless transceiver, which is less power/heat-constraint since it is not at the immediate proximity of the cortex and its radiated signal is not seriously attenuated by the lossy tissue. The gigabit data link has been demonstrated to achieve a high data rate of 6 Gb/s with a bit-error-rate of 10(-12) at a transmission distance of 6 mm, an applicable separation between transmitter and receiver. This high data rate is able to support thousands of recording channels while ensuring a low energy cost per bit of 2.08 pJ/b.

A silicon-based two-dimensional chalcogenide: growth of Si2Te3 nanoribbons and nanoplates.

We report the synthesis of high-quality single-crystal two-dimensional, layered nanostructures of silicon telluride, Si2Te3, in multiple morphologies controlled by substrate temperature and Te seeding. Morphologies include nanoribbons formed by VLS growth from Te droplets, vertical hexagonal nanoplates through vapor-solid crystallographically oriented growth on amorphous oxide substrates, and flat hexagonal nanoplates formed through large-area VLS growth in liquid Te pools. We show the potential for doping through the choice of substrate and growth conditions. Vertical nanoplates grown on sapphire substrates, for example, can incorporate a uniform density of Al atoms from the substrate. We also show that the material may be modified after synthesis, including both mechanical exfoliation (reducing the thickness to as few as five layers) and intercalation of metal ions including Li(+) and Mg(2+), which suggests applications in energy storage materials. The material exhibits an intense red color corresponding to its strong and broad interband absorption extending from the red into the infrared. Si2Te3 enjoys chemical and processing compatibility with other silicon-based material including amorphous SiO2 but is very chemically sensitive to its environment, which suggests applications in silicon-based devices ranging from fully integrated thermoelectrics to optoelectronics to chemical sensors.

Reference values for maximal inspiratory pressure: a systematic review.

BACKGROUND: Maximal inspiratory pressure (MIP) is the most commonly used measure to evaluate inspiratory muscle strength. Normative values for MIP vary significantly among studies, which may reflect differences in participant demographics and technique of MIP measurement. OBJECTIVE: To perform a systematic review with meta-analyses to synthesize MIP values that represent healthy adults. METHODS: A systematic literature search was conducted using Medline, EMBASE, Cochrane, Cumulative Index to Nursing and Allied Health (CINAHL) and Sport Discus databases. Two reviewers identified and selected articles, and abstracted data. Methodological quality was assessed using the Quality Assessment of Diagnostic Accuracy Studies (QUADAS) tool. A random-effects model was used to calculate overall means and 95% CIs. RESULTS: Of 22 included articles, MIP data were synthesized according to age group and sex from six reports (n=840) in the meta-analyses. The mean QUADAS score was 3.5 of 7. The age range was between 18 and 83 years (426 men, 414 women). MIP began to decrease with age in the 40 to 60 years age range and continued to fall progressively with age. For the same age group, men tended to have higher MIPs than women. Sensitivity analysis of withdrawing studies from the meta-analysis identified one study that contributed more to heterogeneity in some age groups. DISCUSSION: MIP was higher in men and decreased with age, which was initially apparent in middle age. Several characteristics of participants and MIP technique influence values in healthy individuals. CONCLUSIONS: The present meta-analysis provides normative MIP values that are reflective of a large sample (n=840) and likely represents the broadest representation of participant characteristics compared with previous reports of normative data.

Safe and effective prescription of exercise in acute exacerbations of chronic obstructive pulmonary disease: rationale and methods for an integrated knowledge translation study.

BACKGROUND: Patients hospitalized with an acute exacerbation of chronic obstructive pulmonary disease (AECOPD) engage in low levels of activity, putting them at risk for relapse and future readmissions. There is little direction for health care providers regarding the parameters for safe exercise during an AECOPD that is effective for increasing activity tolerance before discharge from hospital, especially for patients with associated comorbid conditions. OBJECTIVE: To report the rationale for and methods of a study to develop evidence-informed care recommendations that guide health care providers in the assessment, prescription, monitoring and progression of exercise for patients hospitalized with AECOPD. METHODS: The present study was a multicomponent knowledge translation project incorporating evidence from systematic reviews of exercise involving populations with chronic obstructive pulmonary disease and/or common comorbidities. A Delphi process was then used to obtain expert opinion from clinicians, academics and patients to identify the parameters of safe and effective exercise for patients with AECOPD. RESULTS: Clinical decision-making tool(s) for patients and practitioners supported by a detailed knowledge dissemination, implementation and evaluation framework. CONCLUSION: The present study addressed an important knowledge gap: the lack of availability of parameters to guide safe and effective exercise prescription for hospitalized patients with AECOPD, with or without comorbid conditions. In the absence of such parameters, health care professionals may adopt an 'activity as tolerated' approach, which may not improve physical activity levels in their patients. The present study synthesizes the best available evidence and expert opinion, and will generate decision-making tools for use by patients and their health care providers.

Exercise prescription for hospitalized people with chronic obstructive pulmonary disease and comorbidities: a synthesis of systematic reviews.

INTRODUCTION: The prescription of physical activity for hospitalized patients with acute exacerbation of chronic obstructive pulmonary disease (AECOPD) can be complicated by the presence of comorbidities. The current research aimed to synthesize the relevant literature on the benefits of exercise for people with multimorbidities who experience an AECOPD, and ask: What are the parameters and outcomes of exercise in AECOPD and in conditions that are common comorbidities as reported by systematic reviews (SRs)? METHODS: An SR was performed using the Cochrane Collaboration protocol. Nine electronic databases were searched up to July 2011. Articles were included if they (1) described participants with AECOPD, chronic obstructive pulmonary disease (COPD), or one of eleven common comorbidities, (2) were an SR, (3) examined aerobic training (AT), resistance training (RT), balance training (BT), or a combination thereof, (4) included at least one outcome of fitness, and (5) compared exercise training versus control/sham. RESULTS: This synthesis examined 58 SRs of exercise training in people with AECOPD, COPD, or eleven chronic conditions commonly associated with COPD. Meta-analyses of endurance (aerobic or exercise capacity, 6-minute walk distance--6MWD) were shown to significantly improve in most conditions (except osteoarthritis, osteoporosis, and depression), whereas strength was shown to improve in five of the 13 conditions searched: COPD, older adults, heart failure, ischemic heart disease, and diabetes. Several studies of different conditions also reported improvements in quality of life, function, and control or prevention outcomes. Meta-analyses also demonstrate that exercise training decreases the risk of mortality in older adults, and those with COPD or ischemic heart disease. The most common types of training were AT and RT. BT and functional training were commonly applied in older adults. The quality of the SRs for most conditions was moderate to excellent (>65%) as evaluated by AMSTAR scores. CONCLUSION: In summary, this synthesis showed evidence of significant benefits from exercise training in AECOPD, COPD, and conditions that are common comorbidities. A broader approach to exercise and activity prescription in pulmonary rehabilitation may induce therapeutic benefits to ameliorate clinical sequelae associated with AECOPD and comorbidities such as the inclusion of BT and functional training.

A multi-interface adaptive hypermedia system to promote consumer-provider partnership in chronic disease management.

Much of chronic disease management depends on active partnership of consumer and provider. Our system promotes diabetes management through profiling and adaptive support of both consumer and provider. We use a University Podiatry Clinic and diabetes consumer information portal as inter-related contexts that share profile information.